8 FOREWORD Health is always co-created Health is not only an individual and personal choice. It is the choice of sustainable and resilient societies. This publication pioneers the notion that the responsibility for health doesn t lie within a certain sector, a stakeholder group, or with the individual person. In this guide, we have broken down the walls between societal arenas such as schools, workplaces, food, health care, and cities to showcase that the challenges within health can only be met by an integrated cross-sector approach. Health is a difficult entity. Too often we start thinking about health when it is gone, and even then, we associate it with the health care sector. We view our bodies as machines that can get fixed when they stop working properly. The Sustainia Guide to Health aims at breaking both these assumptions because they are not sustainable. In this guide, we make the case for viewing health as a cross-sector responsibility and as an investment. Health is an investment in your quality of life, in your business, in your students, in your city and, essentially, in yourself. It may surprise you to learn that the number one killer, claiming more than 36 million lives each year, is largely preventable. We die of conditions, such as cancer, diabetes, and heart disease, which are largely caused by physical inactivity, unhealthy diets, and tobacco use. These non-communicable diseases (NCDs) are easier to prevent than to treat. But when arriving at the conclusion that prevention is the answer, the next logical question is: Who is responsible? The health care sector is not a sufficient answer health care costs are skyrocketing around the world and health care systems are still more geared to treat, rather than prevent, poor health. One could also argue that since NCDs risk factors are closely related to an individual s choices, we should continue viewing health as a personal and individual issue but people should know better. It leaves us with a passive and kind of depressing outlook on the future. At the core of this guide is the recognition of health as a shared responsibility that should be infused into every part of our lives. Yes, health is a choice but we have to ask ourselves whether or not this choice is easy, fun, and available. 4 SUSTAINIA GUIDE TO CO-CREATING HEALTH

9 health can be created anywhere, by anyone On this journey we will visit several destinations and explore the possibilities that are activated with health empowerment. The destinations are places we are sure you have visited already but maybe you never thought how they could enhance your health and ultimately your quality of life. We visit schools, workplaces, food, cities, and health care to demonstrate how a focus on health empowerment can create staggering results within each arena. As you will discover, the benefits are not limited to physical and mental well-being, but will also include a better economic, social, and environmental outcome. But while the transformation of entire systems is necessary, and requires the attention of decision makers, our People-Powered Health chapter examines the equally important role of bottom-up initiatives. In this guide, we show how health can be created anywhere, by anyone all that you need is the idea and the support to make it grow beyond its borders. Then again, we realize that this is not completely true. Not everyone lives in regions of the world where basic human rights are a given. For example, it is obvious that talking about health-empowerment in schools falls short in solving problems in regions where education for all is not a reality. But by highlighting the flaws in societal models, we hope to inspire new societies to build more health-resilient communities like the ones we envision in this guide. On this journey towards a health-empowering society, none of us can travel alone. Throughout this publication, we strive to make it evident that stakeholders from seemingly very different arenas are facing the same challenges, and that they all have a stake in creating the solutions. Ultimately, we will discover that health is not only a personal choice; it is the choice of sustainable and resilient civilizations. We can only hope to motivate readers to transform the words from a guide into steps towards a better quality of life, and that this will be the beginning of your journey towards not only adding more years to your life, but more life to your years. Erik Rasmussen CEO of Monday Morning Global Institute & Founder of Sustainia Laura Storm Executive Director of Sustainia FOREWORD 5

10 SETTING THE SCENE FOR HEALTH IN SUSTAINIA Introduction Health is not the same as the absence of illness it is much, much more. It depends on holistic well-being and good quality of life being built into every single day. Traditionally, the health care sector has been relied on solely to cure diseases just as when you have a flat tire on your bike, you take it to the bicycle repair shop. This way of viewing health and health care is no longer sustainable. New solutions are needed to address serious health issues, such as sedentary lifestyles and unhealthy diets, which have been brought on by modernity. Health interventions need to become more focused on the prevention of illness, instead of simply dealing with symptoms when they arise. The challenge we tackle here in the first Sustainia Guide to Co-Creating Health is how communities, governments, industries, schools, and workplaces can function together to create sustainable systems that truly support and encourage healthy choices. Have a think about what influences your health. Is it safe and fun for you to walk and cycle to school or work? Is delicious, affordable, nutritious food available in your local corner shop? Do your children s teachers and your own boss openly prioritize health? What more would you like to be able to do, with the support of those around you? This publication argues that health is a cross-sector responsibility, rather than simply a system of care to fix people when they are broken. The vision is one of a health-empowering society, where health permeates into different parts of life, making healthy choices the norm and not the exception. This guide will show you ways in which good quality of life is good business, good sense, and, crucially, that the solutions we need are already at hand. 6 SUSTAINIA GUIDE TO CO-CREATING HEALTH

11 The Challenge During the first decade of the new millennium, non-communicable diseases (NCDs) were the number one killers, accounting for almost two-thirds of deaths worldwide. 1 The World Health Organization (WHO) definition is: NCDs, also known as chronic diseases, are not passed from person to person. They are of long duration and generally slow progression. The four main types of non-communicable diseases are cardiovascular diseases (heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and type 2 diabetes. 2 NCDs have reached a critical mass in terms of death tolls and health care costs to the degree that they are now one of the biggest threats to the most important resource of all people. A Political Declaration unanimously adopted in 2011 by the United Nations General Assembly on the Prevention and Control of Non-Communicable Diseases recognized NCDs as a threat to the economies of many member states. It also highlighted the critical importance of reducing the level of exposure of individuals and populations to the common modifiable risk factors for NCDs ( ) while at the same time strengthening the capacity of individuals and populations to make healthier choices and follow lifestyle patterns that foster good health. 3 In 2011, the World Economic Forum released the first study to identify the total global costs of NCDs and the following dire projections were made: Over the period between 2011 and 2030, the total economic output lost to NCDs is projected to reach nearly $US 47 trillion. This loss, divided by the 20-year period, is equivalent to about 5% of global GDP in High-income countries bear the highest absolute burden of lost output, reflecting the income that is lost when employees are sick. After 20 years of steady increase in total output losses, the rate is projected to pick up sharply by With these projections in mind, it s safe to say that the time has come for a new health paradigm. The good news is that NCDs can often be prevented or delayed. This leaves us no choice but to view health as a common responsibility, rather than being up to the individual. Bad health can be defined as the result of many unhealthy choices. As such, we must also look at the societies surrounding us and ask ourselves: are healthy options the most prevalent, attractive, and convenient of all? 1 WHO Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases WHO. Noncommunicable diseases. Fact sheet. Mar Online: who.int 3 WHO. Political declaration adopted at the UN General Assembly.United Nations high-level meeting on noncommunicable disease prevention and control: Meeting Outcomes. Jan Setting the scene 7

12 The Opportunity The numerous and profound benefits of a healthy population include a more productive workforce, more attentive students, and even a better bottom line for companies. But the main benefit of living in a health-promoting society is quite simple decent health is a prerequisite for everything else we might want to achieve in life. Our aspirations as individuals, communities, companies, or countries are dependent on healthy people. By identifying and communicating about health-promoting solutions, we have already embarked on a journey that leads to better quality of life. We all need to have a new vision of the future one that is more convenient, fun, easy, and affordable. This new era is ripe with opportunities for solution entrepreneurs, efficient investments, and for expanding corporate social responsibility. We will focus on the qualities of sustainability that contribute to and generate shared value. They are sustainable health solutions that promote a decent quality of life for us now and for future generations. We can easily agree that the following needs are fundamental: food, water, air, shelter, exercise of body and mind through work and play, rest, and healing. In Sustainia, a collaborative and personal effort is required to maintain the availability of these basic necessities because, if any one of these things is missing one simply cannot be well. As Sir Andy Haines, Professor of Public Health Policy at the London School of Hygiene and Tropical Medicine, puts it: Health and sustainability are indivisible at a global level, as improvements in health cannot be maintained without safeguarding the underlying systems on which human health and development depend. 4 Sustainia defines health as being the best version of yourself, both physically and mentally, because of the supportive, health-empowering systems built into your daily life, which make it easy for you to make healthy choices. 4 Haines, A. and Dora, C. How the low-carbon economy can improve health BMJ 2012;344:e1018. Mar 2012

13 Meeting the challenge with a shared language In this publication we will address several groups from individuals to communities to commerce to governments because they are intertwined in the responsibilities of creating a health-empowering society. This cross-sector approach is mentioned as the necessary way forward by the UN Political Declaration on NCDs, in which member states called for a stronger coordination between the relevant interest groups, namely individuals, families, and communities, intergovernmental organizations and religious institutions, civil society, academia, the media, voluntary associations and, where and as appropriate, the private sector and industry. This challenge requires innovation and is one of the most important issues of our time. The magnitude of the task may cause societal systems to shy away from tackling it. Reportedly, the different views and vocabularies that stakeholders adopt in relation to this challenge is a barrier to success. 5 For example, health professionals may talk about well-being, while business leaders refer to productivity even though these success criteria are wholly interdependent on each other. Creating a shared understanding and language is the key for cross-sector collaboration and empowering individuals. These techniques are real and they constitute the means by which we can innovate to a point that we are thriving economically, socially, and environmentally. They also echo one of the reasons why Sustainia was founded the need to gravitate toward a unified language when speaking about sustainability. 5 International Institute for Sustainable Development. Ecohealth and Watersheds Watersheds as Settings for Health and Well-Being in Canada. Research Paper. 2012

14 WHAT IS SUSTAINIA? HEALTH! Sustainia is a clear and realistic vision of a sustainable society. It is a demonstration of how we could live in the future, and a collaborative platform to make it happen. Sustainia is not a utopia or a distant dream. It is built on scenarios in which ready-and-available solutions, innovations, and technologies are implemented on a large scale. Championing the sustainable and exciting societies in which we could live is at the heart of Sustainia s mission. By focusing on possibilities and benefits, we can shape a new narrative of optimism and hope for a sustainable future that inspires and motivates, instead of allowing doomsday scenarios to paralyse us with fear. Citizens, organizations, and companies from all over the world make up the Sustainia community. We believe that change is created bottom-up. This is why we listen, discuss, and develop our work in an open dialogue, and why you will find plenty of case studies of best practices in our publications. We believe in and write about solutions that are available and ready to put to use in building a sustainable world. Sustainia is a part of Monday Morning Global Institute, which is Scandinavia s leading think tank. Monday Morning Global Institute builds on a clear set of values and a deep understanding of the global drivers of change. For twenty-five years, the company has developed a long range of activities and projects through cross-sector partnerships. A common denominator in our projects is the desire to build sustainable and resilient societies.

15 How to use the guide: This guide explores sustainable health as a cross-sector, collaborative responsibility. We have prioritized several societal arenas in which health-promoting interventions can be especially beneficial. Each of the following Arenas of Intervention and the collection of People-Powered Health are dissected in order to examine their predominant challenges and opportunities, while compelling solutions and cases are highlighted. Arenas of Intervention: Schools Workplace Food Cities Health Care People-Powered Health There will be an emphasis throughout this guide on the practicalities and opportunities for developing, replicating, and scaling solutions that improve health. Whether you are a policy maker, business leader, or active citizen, we want to inspire you to initiate change and prioritize health in your community. For this purpose, every Arena of Intervention chapter will include tools to be used for tailoring solutions to various circumstances. There is a focus on sustainable health solutions that are most applicable to developed regions. We understand that solutions that deal with issues of how healthy food can be displayed better in cafeterias will not be relevant to regions suffering from food shortages. But the ambition is that as emerging economies move forward, they can leap-frog over replicating the chronic health problems of developed regions and go straight to designing health-empowering schools, workplaces, and infrastructure. Every paradigm shift and change of practice needs a champion. In turn, these champions need a forum, an audience, and actions to stimulate the debate. If this book could be summarized in just a few lines, it might simply be that there is a correlation between what s good for the planet and what s good for you and that healthy people are the single most important resource in the sustainable transition. HOW TO USE THIS GUIDE 11

16 SUSTAINIA HEALTH PRINCIPLES 1 Everyone has the opportunity to live a healthy life 2 High levels of health literacy are ensured for all citizens 3 Health is integrated into all school activities 4 Workplaces foster healthy lifestyles for employees, their families, & the greater community 5 All have access to a nutritious food supply with healthy levels of salt, fat, sugar, & alcohol 6 Active transport is a top priority when planning urban infrastructure 12 SUSTAINIA GUIDE TO CO-CREATING HEALTH

17 7 Nature & wildlife outside of cities are protected as essential resources, & cities include ample green spaces & urban farms. 8 Climate adaptation solutions are combined with public healthpromoting components 9 Health care is performed with people at the center of all decisions 10 Communities are given tools & support to create health initiatives that fit their unique needs SUSTAINIA HEALTH PRINCIPLES 13

19 IF YOU VE ONLY GOT 5 MINUTES The essential introduction to health & sustainability for If you ve only got 5 minutes 15

20 The new policy maker What you should know: Thinking beyond the traditional health care sector for public health initiatives yields large returns. For example, investments in children s health in schools result in better-educated and more productive adults - PAGE 25 Lost economic output due to non-communicable diseases (NCDs) amounts to about 5% of global GDP annually - Page 7 An estimated one third of food produced globally goes to waste, but only 5% of agricultural research investment focuses on postharvest issues, while 95% is spent on increasing production - Page % of the world s population will be living in cities by 2050 (as opposed to 40% in 1990), making urban areas an essential target for health policies - Page 118 New health care models and new financial structures are needed to meet the increasing social and economic burden of NCDs, such as the projected health care spending to rise from 6.2% to 14% of GDP by 2060 in OECD countries - Page 149 What you should do: Create policies where the financial incentives are focused on prevention, and support health interventions in all arenas, not only the health care sector Design cities with an active transport infrastructure and access to green spaces for all Establish supportive conditions for shops, services, cafes, cultural centers, etc. the features of a walkable city Make vacant land available to urban farmers and support community farming efforts Leverage the benefits of nature in city planning as efficient investments in public health Support the education and training of health care professionals in personcentered care ECONOMIC LOSS IN TRILLIONS OF DOLLARS FROM PREVENTABLE DISEASES - page Total World Countries High Income Countries Total, Low & Middle Income $ Trillions SUSTAINIA GUIDE TO CO-CREATING HEALTH

21 THE NEW BUSINESS LEADER What you should know: Research is showing that companies with a strong health culture outperform their competitors - Page 57 Consumer demand for healthy and sustainable products is dramatically increasing. From 2000 to 2011, demand for organic food in the US has almost quadrupled to an annual market of over $US 29 billion per year - Page 92 Workplace health interventions impact productivity. A study showed that employees with an unhealthy diet were 66% more likely to experience a loss in productivity than those who were able to include fruit, whole grains, and vegetables in their lunch and snack times - Page 70 WHO stresses that the health-empowering workplace will be a prerequisite for economic development - Page 70 The private sector is playing a key role in creating solutions and services to meet demand from the increasing problem of NCDs - Page 153 What you should do: Lead by example top management must build health into all business plans and should themselves openly demonstrate healthy choices Develop health initiatives in partnership with employees to meet your group s unique health needs Provide nutritious food, take measures against sedentary work conditions, offer smoking-cessation support, and adapt the company s built environment to one with health-promoting features Take advantage of your organization s role in society and extend health initiatives to employees families and the local community COMPANIES WITH A CULTURE OF HEALTH PERFORM BETTER - page 57 $25,000 $20,000 $15,000 $10,000 $19, $9, $5, S&P 500 Corporate Health Achievement Award Winners If you ve only got 5 minutes 17

22 THE NEW HEALTH PROFESSIONAL What you should know: The role of a health professional is increasingly to act as a health guide who empowers people to preserve their health, rather than only dealing with diseases - Page 164 Improved cost savings and well-being can be achieved when patients, families, and communities are more directly involved in the management of long-term health conditions - Page 154 NCDs are the number one killer in the world, accounting for more than 63% of all global deaths - Page % of people with NCDs can manage their own condition through acquiring selfcare skills - Page 161 Future health care systems will focus more on health outcomes, rather than the quantity of treatments delivered - Page 164 What you should do: Take on the role of a health guide for the people you serve, including their families and community Educate yourself on enhanced skills of listening, communication, and teamwork Adopt a new language that is free from jargon and terms that put you and the patient on unequal footing Place importance on initial dialogues to increase your understanding of the person s needs and circumstances, and not only focusing on the medical side of the problem Prepare for evaluations and financial incentives that focus on prevention From a focus on sickness TO A focus on being well Global deaths (in millions) DEATHS FROM NCDs ARE PREDICTED TO RISE DRAMATICALLY - Page Non-communicable diseases 80 Infectious diseases 70 Injuries From a predominantly medicalized approach TO A more holistic approach that empowers individuals & communities From professional-centered TO Person-centered From isolated & segregated TO Integrated & in partnership From institution-focused health TO Community-focused health 18 SUSTAINIA GUIDE TO CO-CREATING HEALTH

23 THE NEW COMMUNITY LEADER What you should know: Health isn t a product of the health care system, it starts where we live, learn, work, and play in our communities - Page 178 People-powered health is both effective and inspiring - Page 178 Local communities can help tackle the disease risk factors of poor diet, lack of physical activity, harmful use of alcohol, and smoking - Page 144 The future health care sector will focus more on reaching out to communities for health empowerment and treatment. This means that they will actively be looking for community partners - Page 144 Schools and some workplaces have facilities that are frequently left unused after hours. Community initiatives can make use of these facilities for sports, dance, and drama all of which make citizens more active - Page 47 What you should do: Reflect on the health-empowering strengths you have and how you can influence others Use tools to engage your community and develop customized health interventions - Page 191 Reach out to local health care professionals, associations, politicians, co-workers, and school officials to form strategies to support community health initiatives Share your people-powered health stories the successes and the challenges will inspire action If you ve only got 5 minutes 19

24 SCHO 20 SUSTAINIA GUIDE TO CO-CREATING HEALTH

25 OLS schools 21

26 THE WALKING SCHOOL BUS

27 Schools

28 A HEALTHY START IN LIFE Introduction A global snapshot tells us that nearly 700 million children are enrolled in primary school 1 and that on average a child spends 779 hours there each year. While schools have the responsibility of forming young people into successful, educated adults later in life, they also have the potential to lay a foundation of health for coming generations. In Sustainia, health literacy means knowing what causes good health and being capable of making healthy choices. Health literacy in Sustainia s schools is just as important a criterion for success as accomplishments in reading, writing, and math. According to the World Health Organization, children s choices, diet, and physical activity habits are influenced by their surrounding environments. This makes school an obvious arena for forming healthy habits early on, which is easier than breaking bad ones later in life. Research shows that if we establish an unhealthy lifestyle during our early years, it is likely to follow us for the rest of our lives. 2 WHO mentions schools as settings for action in the prevention and control of NCDs. It urges member states to include appropriate health-empowering strategies in school health programs and in programs geared towards youth, 3 while emphasizing that advantages and disadvantages in health and its social determinants accumulate over the life course. 4 Equipping future generations with the right habits and knowledge on how to live healthier and more sustainable lives is not only about reversing the upward trend in the occurrence of chronic illnesses and obesity it is about empowerment, self-fulfillment, and good quality of life. It is also makes good economic sense, as preventing chronic diseases could save a lot of money in terms of productivity loss and absenteeism. 1 UNESCO Institute for Statistics. Number of children enrolled in primary. Public and private. All programs. Total in Online: 2 Nike, Inc. Designed to Move: A Physical Activity Action Agenda Online: 3 WHO Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases Marmot, M. et al. WHO European review of social determinants of health and the health divide. The Lancet, vol. 380, pg Food and Agriculture Organization of the United Nations. Nutrition Education in Primary Schools Vol. 2: The Activities SUSTAINIA GUIDE TO CO-CREATING HEALTH

29 According to the Food and Agriculture Organization of the United Nations, health, education, and nutrition go hand-in-hand with creating a sustainable society. Adapted here are several of its reasons for why schools are a great arena for focusing on health: 5 SCHOOLS WORKPLACE why schools are a great arena for focusing on health: FOOD Have a mandate to guide young people towards maturity and, health empowerment is part of this responsibility Spread the effect by involving families Have qualified personnel to teach and guide Can be a channel for community participation CITIES Reach children at a critical age when habits and attitudes are being established Can establish school policies and practices, such as sanitation facilities or rules about hand-washing, that can improve health HEALTH CARE Reach most children over a number of years on a regular basis Provide opportunities to practice healthy eating and active lifestyles Can provide cost-effective interventions PEOPLE POWERED HEALTH schools 25

30 GENERATION OBESE The Challenge Approximately 170 million children,18 years or younger, are now estimated to be overweight, and WHO identifies childhood obesity as one of the most serious public health challenges of the 21st century because of the far reaching consequences. The alarming indicator of rising rates of childhood obesity worldwide today is a serious warning for health in the future. The root causes of excessive weight gain have been identified as sedentary lifestyles and diets with too much fat, salt, and sugar, often associated with food containing empty calories a combination of high-energy, low-nutrient properties (think French fries, soda, sweets, and pizza.) 6, 7 Overweight children are likely to become obese adults and they are more prone to developing diabetes and cardiovascular diseases at a younger age, 8, 9 but they also face more immediate health issues. The US Centers for Disease Control and Prevention (CDC) state that obese children are at risk of pre-diabetes, bone and joint problems, sleep apnea, and social and psychological problems, such as stigmatization and poor self-esteem Reedy J, Krebs- Smith S.M. Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States. Journal of the American Dietetic Association, vol. 110, pg Brennan, B. US government seeks to ban candy and sugary beverages from schools, FoodAlert, Bord Bia. 2010, Feb. Online: 8 WHO. 10 facts on obesity 2013, Mar. Online: 9 Onis, M., Blössner, M. and Borghi, E. Global prevalence and trends of overweight and obesity among preschool children The American Journal of Clinical Nutrition, vol. 92, pg % Overweight INCREASING NUMBER OF OVERWEIGHT CHILDREN AROUND THE WORLD US Iceland Chile Japan England Scotland Germany Australia 10 Centers for Disease Control and Prevention. Childhood Obesity Facts. July Online: 11 BBC. Obesity: in statistics. BBC News. Jan Online: SUSTAINIA GUIDE TO CO-CREATING HEALTH

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